Assignment
Assignment
A). What is the problem representation of this patient and what is the anatomical localization for her current problem based on the clinical findings?
Ans:
problem presentation
in order of priority at the time of admission:
1)altered sensorium with irrelevant talk since 1 day
2)neck pain with headache since one month which worsened for the past 8 to 15 days
3)vomitings since one week
4)low grade fever since one week
5)generalised weakness with decreased appetite since one month
anatomical localisation of current problems
Brain-meninges and ?frontal lobe, due to altered sensorium
B)What is the etiology of the current problem and how would you as a member of the treating team arrive at a diagnosis? Please chart out the sequence of events timeline between the manifestations of each of her problems and current outcomes.
b) Etiology: CVA , TB Meningitis , SLE vasculitis ,SIADH secondary to infection.
Initially the first on-call team thought it was Hyponatremia that is secondary to SIADH which is causing altered sensorium.. and also MRI was done which showed stroke the second on call team with further work up decided to do LP which showed the CSF positive for CBNAAT. Thus came to the diagnosis of TB Meningitis.
C)What is the efficacy of each of the drugs listed in her prior treatment plan that she was following since last two years before she stopped it two weeks back?
C) Bisphosphonates were given to prevent osteoporotic fracture risk associated with using long-term steroids.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5357611/Bisphosphonate prophylaxis
D)Please share any reports around similar patients with SLE and TB meningitis?
d) Probable cause of normal CSF count in patients of Chronic meningitis is probably due to the use of steroids which caused immunosuppression and decreased inflammatory response.
was the research question in the above thesis presentation?
The research question
1)will salt restricted diet decrease blood pressure?
2)can 24hr urinary sodium test reflect the amount of sodium consumed by an individual
What was the researcher's hypothesis?
Hypothesis is that, salt restriction doesn't effect blood pressure in all the individuals in the same way, and salt resistant individuals don't benefit from a restricted diet as much as a salt sensitive individual.
What is the current available evidence for the utility of monitoring salt excretion in the hypertensive population
The 24hr urinary sodium is a reflection of dietary sodium, and has better results than dietary recall method
Daily salt intake based on 24-hour urinary sodium excretion (assuming that all sodium ingested was in the form of sodium chloride) with a formula: figure 2 shows a practical method to estimate salt or sodium intake.
Figure 2: Calculation for estimation of salt or sodium intake
Na (mg/day) = Na (mmol/day) x 23; NaCl = Na (g/day) x 100/ 39,3
1 gram salt (NaCl) = 393,4 mg Na = 17,1 mmol Na
What was the research question in the above thesis presentation?
The research question in the above thesis is whether magnesium plays a role in complications of diabetes mellitus
What was the researcher's hypothesis?
The researcher's hypothesis is that hypomagnesemia causes complications of dm2 irrespective of other confounding factors like age,duration of diabetes.
What is the current available evidence for magnesium deficiency leading to poorer outcomes in patients with diabetes?
In this retrospective study 673 diabetic patients were evaluated.
According to Mg levels, the patients were divided into two groups; as normomagnesemic patients and hypomagnesemic patients.
There were 55 patients (8.2%) with diabetic retinopathy and 95 patients (14.1%) with diabetic neuropathy. Five hundred patients (74.3%) had normoalbuminuria; 133 patients (19. 8%) had microalbuminuria (MA) and 40 patients (5.9%) had overt proteinuria. One hundred and seventy one patients (25.4%) had HbA1c levels equal or below 7%; and 502 patients (74.6%) had HbA1c levels above 7%. There was no statistical difference in age or duration of diabetes between the groups formed according to Mg levels. Although there were no differences between the groups for retinopathy and neuropathy, MA was more common in hypomagnesemic patients (p =0.004). HbA1c levels did not differ between the groups (p =0.243). However there was a weak negative correlation between serum Mg and HbA1c levels (r =-0.110, p =0.004) and also between serum Mg and urine protein level (r =-0.127, p =0.018
3)Please critically appraise the full text article linked below:
What is the efficacy of aspirin in stroke in your assessment of the evidence provided in the article. Please go through the RCT CASP checklist here https://casp-uk.net/casp-tools-checklists/ and answer the questions mentioned in the checklist in relation to your article.
Clinical appraisal of the article:
1)The study answered the research question
being the use of asprin for prevention of stroke progression.
it was foccused in terms of intervention given and outcome measured
2)the method for randomisation was appropriate eliminating systematic bias and allocation sequence concealed from investigators and participants
3)all the participants included in the study were accounted for, including rhe two parcels whixh were accidentally opened.
4)the participants and the investigators were blind methodically
5)the study groups were similar
6)apart from the experimentation, the hospital care given is not documented
7)there were dropouts in the study, study medication was interrupted in few due to suspected side effects,
the p value was not mentioned
8)the cI interval 95%0.6-1.45
9)the treatment effect wasn't much,
10)the outcomes are benefial to my population in prescribing anticoagulants
dual vs single antiplatelet use and longer duration of followup could have been made .
4) Please mention your individual learning experiences from this month.
-Nephrotic syndrome
-Budd-chiari syndrome
-Cardio-thoracocentisis
-Alcohol induced gastritis
-Acute pancreatitis and its duration to turn into chronic pancreatitis
-NSAID induced AKI
-Bleeding manifestations after LMW therapy for post cardiac arrest
-Pleural effusion in inadequate dialysis
-Asicitis due to inadequate dialysis
-Dd of chronic headache.
5) a) What are the possible reasons for the 36 year old man's hypertension and CAD described in the link below since three years?
The possible reasons for hypertension and cad in the given history could be
Alcohol
The HPFS is a prospective investigation of 51 529 US male dentists, pharmacists, veterinarians, optometrists, osteopathic physicians, and podiatrists aged 40 to 75 years who returned a mailed questionnaire about diet and medical history in 1986.
At baseline, men reported their alcohol consumption on a 131-item semiquantitative food frequency questionnaire (FFQ) that included separate items for beer, white wine, red wine, and liquor. Participants were asked how often, on average over the past year, they consumed each beverage. We calculated total alcohol intake by multiplying the average consumption of each beverage by the alcohol content of the specified portion size (12.8 g for beer, 11.0 g for wine, and 14.0 g for liquor) and summing across beverages. The FFQ was administered again every 4 years, with an item for light beer added in 1994. Participants also reported their overall drinking frequency in 1986, 1988, and 1998.
results:
When we compared alcohol intake of 5.0 g/d or more vs less than 5.0 g/d, the hazard ratio was 0.58 (95% CI, 0.37-0.89). Given that 55% of person-time was contributed by consumers of 5 g/d or more of alcohol, we estimate that 25% of the incidence cases of MI in this population were attributable to consuming less than 5 g/d (95% CI, 11%-47%).
Smoking
Temporal Associations Between Smoking and Cardiovascular Disease, 1971 to 2006 (from the Framingham Heart Study)
b) Please describe the ECG changes and correlate them with the patient's current diagnosis.
The ecg suggests:
1st ecg-irregularly irregular rythmn,normal axis,
Intermittent broad qrs complexes ? ventricular escape rythmn,?idioventricular rythmn
Remaining ecg-poor r wave progression with regular rythmn
c) Share an RCT that provides evidence for the efficacy of primary PTCA in acute myocardial infarction over medical management. Describe the efficacy in a PICO format.
RITA-2 is a randomized control trial published in
Journal of the American College of Cardiology Clinical Trials Vol. 42, No. 7, 2003 © 2003 by the American College of Cardiology Foundation Published by Elsevier Inc.
P-1018,Patients were recruited at 20 centers in the U.K. and Ireland. In brief, patients with arteriographically proven coronary artery disease (CAD) were considered for the trial if the supervising cardiologist thought that continued medical therapy and PTCA were both acceptable treatment options. Patients had to be over 18 years of age, but there was no upper age limit.
I-The 1,018 patients were randomized to coronary angioplasty (n 504) or continued medical treatment (n 514) from July 1992 to May 1996. Follow-up to September 30, 2001, is included in this report, the median follow-up period being seven years.
C-compared based on death and MI
subsequent interventions required
relief of symptoms of angina and breathless
O-Death or myocardial infarction (MI) occurred in 73 (14.5%) PTCA patients and 63 (12.3%) medical patients (difference 2.2%, 95% confidence interval 2.0% to 6.4%, p 0.21). There were 43 deaths in both groups, of which 41% were cardiac-related. Among patients assigned PTCA 12.7% subsequently had coronary artery bypass grafts, and 14.5% required additional non-randomized PTCA. Most of these re-interventions occurred within a year of randomization, and after two years the re-intervention rate was 2.3% per annum. In the medical group, 35.4% required myocardial revascularization: 15.0% in the first year and an annual rate of 3.6% after two years. An initial policy of PTCA was associated with improved anginal symptoms and exercise times. These treatment differences narrowed over time, mainly because of coronary interventions in medical patients with severe symptoms.
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